Patients with impacted foreign bodies in the upper aerodigestive
tract present commonly to ENT clinics. This case report highlights two
important issues in the management of these patients. First, if the
evidence of esophageal perforation is strong and contrast swallow is
negative, the physician must consider further imaging, such as contrast
computed tomography. Second, ENT physicians must beware of the
complications of esophageal trauma, including major vascular injury and
aortoesophageal fistula, in patients with retained sharp foreign bodies
in the mid-esophagus.

Introduction

Aortoesophageal fistula is a catastrophic complication of foreign
body ingestion. ENT physicians frequently see patients with impacted
foreign bodies in the upper aerodigestive tract. In Birmingham City
Hospital, 133 admissions due to esophageal foreign body impaction were
recorded between 2000 and 2004. (1) We present a pediatric case of
aortoesophageal fistula developing 6 days after removal of a chicken
bone via rigid esophagoscopy.

Case report

A 14-year-old girl presented to the Accident and Emergency
Department with sharp central chest pain. She recalled having eaten
chicken the night before without complaint. She was hemodynamically
stable, and fiberoptic nasendoscopy was negative. She was admitted
directly under the care of Otolaryngology for observation. She developed
a temperature of 38.5[degrees]C overnight.

On day 2, the patient was still in pain. She was stable and her
temperature was normal. Flexible gastroscopy revealed a chicken bone
impacted at 27 cm (figure). The bone was grasped but not dislodged; we
then removed it via rigid esophagoscopy. Pus flowed from the left wall
of the esophagus, and we noted mild ulceration on the right wall. A
postoperative chest x-ray showed no pneumomediastinum.

By day 5, after intravenous antibiotics and analgesia, the patient
had been asymptomatic and apyrexial for 24 hours and was discharged. On
the evening of day 6, however, she returned to the Accident and
Emergency Department with central stabbing chest pain radiating to the
back. The pain was of sudden onset and occurred when she was taking
tablets. In that department she was observed to have vomited 200 ml of
blood. She developed signs consistent with Grade II hypovolemic shock.
After resuscitation with crystalloid, her hemoglobin dropped from 14.8
g/dl to 9.8 g/dl.

A repeat chest x-ray was unremarkable, and an urgent contrast
swallow with Gastrograffin demonstrated no perforation. The patient
decompensated further and required resuscitation with blood products.
She was transferred urgently to tertiary level services.

Flexible esophagogastroscopy demonstrated a bleeding point. A
Sengstaken-Blakemore tube was inserted. Pressures above the systolic
blood pressure were required to gain hemodynamic control. A diagnosis of
aortoesophageal fistula was made, and an emergency thoracotomy was
performed. Primary repair of the esophagus and aorta was conducted.

Despite our patient's recovery over days, resulting in
discharge to the general wards, a rebleed mandated revision surgery and
grafting of the aorta.

Discussion

Impaction of foreign bodies in the upper aerodigestive tract is a
common presentation. Coins, fish bones, and toy parts can become
impacted in the palatine tonsils, base of the tongue, pyriform fossa,
vallecula, or at the classic points of narrowing in the esophagus. In a
study of more than 400 patients, the most common sites of foreign body
impaction within the esophagus were at the level of the postcricoid
region (57%), the aortic arch and left main bronchus (26%), and the
distal gastroesophageal junction (17%). (2)

[FIGURE OMITTED]

In the same study, aortoesophageal fistula occurred in only 1
patient, who subsequently died. (2) Scher et al cited 86 cases of fatal
aortoesophageal fistula. (3) Other complications such as retroesophageal
abscess, mediastinitis, and pneumothorax are well recognized. (4) Rarer
complications include pericardial injury, resulting in cardiac
tamponade. (5) and migration of fish bones to the thyroid and liver in
association with upper esophageal and gastric perforations,
respectively. (6,7)

Aortoesophageal fistula presents with a Chiari's triad of
chest pain, a symptom-free interval, and a transient, self-limiting
"herald bleed." (4) When untreated, this series of symptoms
precedes a fatal hemorrhage.

When there is a delay between foreign body ingestion and
presentation, the aortic perforation may become mycotic. Our patient had
an interval of 6 days between presentation and the initial bleed. An
average symptom-free interval of 8 days is recorded in the literature.
(8)

Identifying the presence and site of the foreign body and
conducting early and safe retrieval are key principles of management.
Most foreign bodies are satisfactorily retrieved by ENT surgeons with
rigid esophagoscopy and grasping forceps. Elegant techniques are
described by Chevalier Jackson. (9)

If esophageal perforation is suspected, current practice recommends
urgent investigation. The initial definitive test is a contrast swallow.
If a perforation is diagnosed, further imaging is required to exclude
vascular involvement. In our case, the test yielded a false-negative
result. Computed tomography of the chest was reported to identify an
aortoesophageal fistula in 2 cases in the literature. 10. (11) This
prompted surgery in both cases, with favorable outcomes.

We believe this case highlights two important issues. First, if the
evidence for a perforation is strong, the physician should consider
further imaging, even if the contrast swallow is negative as it was in
the present case. Second, ENT physicians must beware of the
complications of major vascular injury in patients with retained sharp
foreign bodies in the mid-esophagus.